Reintervention After Heller Myotomy for Achalasia: Is It Inevitable?

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Presentation transcript:

Reintervention After Heller Myotomy for Achalasia: Is It Inevitable? Siva Raja, MD, PhD, Dean P. Schraufnagel, MD, Eugene H. Blackstone, MD, Sudish C. Murthy, MD, PhD, Prashanthi N. Thota, MD, Lucy Thuita, MS, Rocio Lopez, MS, Scott L. Gabbard, MD, Monica N. Ray, MD, Neha Wadhwa, MD, Madhu R. Sanaka, MD, Andrea Zanoni, MD, Thomas W. Rice, MD The Annals of Thoracic Surgery Volume 107, Issue 3, Pages 860-867 (March 2019) DOI: 10.1016/j.athoracsur.2018.09.059 Copyright © 2019 The Society of Thoracic Surgeons Terms and Conditions

Fig 1 Prevalence of symptoms during follow-up after Heller myotomy. (A) Any symptom. Solid line enclosed within a 68% confidence band represents estimates that account for repeated assessments. Symbols represent data grouped within time frames, without regard for repeated assessment, to provide crude verification of model fit. (B) Solid dysphagia and (C) liquid dysphagia. Blue lines represent type I achalasia, red lines, type II, and green lines, type III. These were crude frequencies not accounting for repeated assessments across time. Pre-Heller myotomy (Pre) prevalence is shown by the three corresponding filled circles; green and red circles overlap. The Annals of Thoracic Surgery 2019 107, 860-867DOI: (10.1016/j.athoracsur.2018.09.059) Copyright © 2019 The Society of Thoracic Surgeons Terms and Conditions

Fig 2 Freedom from reintervention after Heller myotomy (all achalasia types). Each symbol represents the first reintervention and vertical bars represent 68% confidence limits equivalent to ±1 SE; solid line enclosed within dashed 68% confidence band represents parametric estimates. The Annals of Thoracic Surgery 2019 107, 860-867DOI: (10.1016/j.athoracsur.2018.09.059) Copyright © 2019 The Society of Thoracic Surgeons Terms and Conditions

Fig 3 Association of achalasia type with reinterventions after Heller myotomy. (A) Instantaneous risk (hazard function) of reintervention according to achalasia type. (B) Cumulative reinterventions per patient by achalasia type. Each symbol represents a reintervention and vertical bars represent 68% confidence limits; solid lines enclosed within dashed 68% confidence bands represent parametric estimates. The Annals of Thoracic Surgery 2019 107, 860-867DOI: (10.1016/j.athoracsur.2018.09.059) Copyright © 2019 The Society of Thoracic Surgeons Terms and Conditions

Fig 4 Cumulative risk of surgical intervention for all types of achalasia after Heller myotomy. Each symbol represents a reintervention and vertical bars represent 68% confidence limits equivalent to ±1 SE; solid line enclosed within dashed 68% confidence band represents parametric estimates. The Annals of Thoracic Surgery 2019 107, 860-867DOI: (10.1016/j.athoracsur.2018.09.059) Copyright © 2019 The Society of Thoracic Surgeons Terms and Conditions

Fig 5 Pattern of symptoms with and without reintervention. Depiction is as in Figure 1, but without confidence bands. Blue curves represent patients after either myotomy without reintervention within the follow-up period (dashed with open circles) or eventual first reintervention (solid with closed circles), where time zero is the Heller myotomy. Red curves represent patients who had a first reintervention, but thereafter either had no further reintervention during follow-up (dashed with open squares) or experienced a subsequent reintervention (solid with closed squares), where time zero is time of first reintervention after Heller myotomy. The Annals of Thoracic Surgery 2019 107, 860-867DOI: (10.1016/j.athoracsur.2018.09.059) Copyright © 2019 The Society of Thoracic Surgeons Terms and Conditions

Fig 6 Repeated reinterventions after Heller myotomy. Orange line with closed circles is freedom from a first reintervention. Patients who experience a first reintervention are restarted at time zero. Purple line with squares is freedom from a second reintervention after having experienced a first reintervention. Vertical bars represent 68% confidence limits. The Annals of Thoracic Surgery 2019 107, 860-867DOI: (10.1016/j.athoracsur.2018.09.059) Copyright © 2019 The Society of Thoracic Surgeons Terms and Conditions